• 의료법학
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• 제8권1호
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• pp.137-177
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• 2007

The medical expenses review system in Korea has developed under fee-for-service system with its own unique structure. The importance of reviewing medical expenses has been emphasized, as the size of medical expenditures moving through the health insurance legal context and its weight in the national economy have increased very rapidly. It is, however, analyzed that the feuds and arguments continue among the stakeholders for the lack of laws supporting the medical expenses review system. The medical expenses review is a series of administrative procedures, deciding whether claims from medical care institutions to the insurer are legal and valid or not. It mainly controls the increase of unnecessarily excessive health insurance claim and prevents fraudulent claim and abuse and checks the less use or unsuitable use of medical resources. It also works a function guarantees medical benefits for the appropriate treatment according to the object of health insurance system as a social insurance scheme. The dispute on legal base of the medical expenses review is about the source of law in the medical expenses review. There are the Health Insurance Act and administrative laws as jus scriptum and the guidelines of review as administrative orders. The medical expenses review should reflect various factors, such as the development of medical healthcare technologies, the health expenditures distribution, the financial situation of the health insurance, and the evaluation on the level of appropriate benefits. It is also likely to adapt to the traits of characters of medicine, and trends and transition, Besides it should judge the legality and the validity of medical benefits expenditures by synthesizing these all factors. And the evaluation system of appropriateness of medical benefits was administrative procedure which was consecutive with reviewing the medical expenses system and it was intended to make up for the result of reviewing the medical expenses in more comprehensive levels.

• 한국방사선학회논문지
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• 제12권7호
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• pp.869-877
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• 2018

본 연구는 MRI 건강보험 급여기준 적용 연혁과 건강보험 청구 자료를 바탕으로 MRI 진료 현황(검사 수, 진료금액)을 분석하여 추후 MRI 급여기준 확대 시 참고할 수 있는 기초자료를 제공하기 위해 시행되었다. MRI 검사가 급여로 적용되기 시작한 것은 2005년으로 초기에는 일부 질환에 대해서만 적응증이 제한되었으나, 2010년, 2013년, 2016년, 2018년 급여 대상이 확대되었으며, 보건복지부는 2021년에는 모든 MRI 검사에 대해 건강보험을 적용키로 하였다. 2010년부터 2017년까지 MRI 검사수와 진료금액 변화는 검사수는 2010년 대비 2017년도에 86.7% 증가하였고, 진료금액은 53.5% 증가하였다. 일반적 특성에 따른 MRI 진료현황은 여성이 남성보다 검사수가 많았고, 연령별로는 70-79세 연령대가 검사수가 가장 많았다. 진료 형태는 외래 검사가 입원검사 보다 많았으며, 의료기관 형태에 따라서는 상급종합병원의 검사수가 가장 많았다. 검사 부위별로는 뇌 MRI 검사수가 가장 높은 비율을 차지하였다. 2013년 12월 심장질환과 크론병에 급여 확대에 따른 진료 현황 변화를 분석한 결과 심장 MRI와 복부 MRI 검사수가 2013년 대비 2014년에 증가하였다. 하지만 전체 대비 검사수가 차지하는 비율이 낮고 질병명과 연계하지 못한 제한점으로 전체 MRI 검사수 증가에 영향을 주었다고 보기는 어려울 것이다. 우리나라는 건강보험 보장성 강화를 위하여 MRI 급여기준을 지속적으로 확대하고 있다. 건강보험 지속가능성과 정책 효과 평가를 위해 추후 지속적인 모니터링이 필요할 것이다.

• 한국병원경영학회지
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• 제8권2호
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• pp.93-110
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• 2003

Fiscal crisis in the medical insurance has put the pressure upon hospitals by increasing the rate of curtailment, since the implementation of the separation between prescription and dispensing of Drug. The purpose of this study is to analyze the curtailment for antibiotics, injected drug and other drugs expenditure before and after the system of separation between prescribing and dispensing. Data were gathered from 13 general hospitals and used for analysis of trends on antibiotics and injected drug expenditure, and curtailment in 2000-2001 at three months intervals. The results were as follows; The curtailment rate of antibiotics expenditure has been increased in outpatient and inpatient since 2000. The curtailed antibiotics cost and injected drug cost in outpatient under the prescription within the hospital and in inpatient increased. The ratios of curtailment versus expenditure had increased in antibiotics, injected drugs, anticancer drugs, antiulcer drugs, albumine, antiinflammatory drugs. These results suggest that claim review system in social health insurance were over-focused mainly to control the cost and it might to impede the validity of claim review function in health insurance system. Therefore, it's needed to develope the scientific and reasonable parameter & criteria for claim review of drug expenditure.

• 한국항해학회지
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• 제25권4호
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• pp.487-512
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• 2001

In 1986, the People's Insurance Company of China(hereinafter called PICC) Hull Insurance Clauses, which were amended on the basis of the version 1972, were put into effect. Since PICC is the biggest state-owned insurance company in China, its hull insurance clauses have been used nationwide. In the clauses are included the following contents： scope of cover, exclusions, period of insurance, automatical termination of insurance, duty of assured, claim and indemnity, treatment of disputes and so on. However, this study is only limited to the legal interpretation of the most important clauses relating to indemnity of the insurer. The writers attempt to supply some basic materials necessary for the establishment and enforcement of the Korean hull insurance clauses.

• Asia pacific journal of information systems
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• 제31권4호
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• pp.527-542
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• 2021

The government-driven open data policies are on the rise to protect consumers from misunderstandings and monitor the companies. However, in contract-based industries such as insurance, the contract-inherent characteristics make information asymmetry between consumers and companies. Our paper focuses on insurance contracts where the contingency has high uncertainty of occurrence, and the clauses may incur high costs of reading. Given those contracts, we hypothesized that the contract's clear statement decreases customer dissatisfaction and lowers the number of complaints. To empirically support the claim, we collected customers' complaint documents of insurance companies and insurance contracts from 2005 until 2017. Our econometric models showed that clearer statements and words significantly reduce the complaints after controlling for firm-specific heterogeneity and time-specific heterogeneity. We identify that insurance companies' complaint ratio significantly differ depending on the insurance contract, including specific clauses and words.

• 한국융합학회논문지
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• 제12권10호
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• pp.137-144
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• 2021

이 연구는 치과 종사자들의 치과 건강보험 교육경험 및 교육요구도와 산정기준에 대한 지식수준에 미치는 요인을 분석하는 것을 목적으로 한다. 대구·경북 지역의 치과 종사자들을 연구대상으로 하였으며, 구글 설문지를 활용한 온라인 조사를 실시하였다. 연구대상자의 일반적 특성, 교육 경험, 교육 경험 및 교육요구도에 따른 지식수준을 알아보기 위하여 빈도분석과 교차분석 및 ANOVA분석을 사용하였다. 분석 결과, 치과 건강보험에 대한 지식수준 조사에서 청구 프로그램에서 자동으로 처리를 해주거나 오류창으로 알려주는 경우의 산정기준에 대한 오답률이 높았다. 근무경력이 많고 치과에서 보험청구를 하고 있거나 최근 6개월 동안 치과보험 교육 경험이 있는 대상자들에서 산정기준에 대한 지식수준이 높았다. 결론적으로, 정기적인 치과 건강보험 교육을 통해 변경되는 산정기준을 숙지하도록 해야만 정확하고 올바른 보험청구가 가능하다고 보여진다. 이 연구는 치과 종사자들의 전문적인 치과 보험청구를 위한 교육체계 마련에 기초자료를 제공할 것으로 기대한다.

• Journal of Acupuncture Research
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• 제27권3호
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• pp.137-146
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• 2010

Objectives : While there are many studies about treatments of facial palsy, no study has been performed on general population of Korea, especially concerning about comparison between western medicine and oriental medicine. This study aimed to investigate magnitude of health visits and treatment patterns for Korean patients with facial palsy through the computerized database of Health Insurance Review and Assessment Service(HIRAS). Methods : According to the HIRAS database over 5 years' period from 2004 to 2008, the medical records of patients with facial palsy as a main diagnosis were extracted. Inclusion criteria of facial palsy are Bell's palsy(G510), Geniculate ganglionitis(G511), Melkersson's syndrome(G512), Other disorders of facial nerve(G518), Disorder of facial nerve, unspecified(G519) in western medicine. And Paralytic face(G016), Deviated eye and mouth(J01), The other facial palsy(J013) were included in oriental medicine. We compared the claim number of western medical care with that of oriental medicine treatment by year and month. Results : The total claim number of facial palsy was increasing on both western medicine and oriental medicine from 2004 to 2008. In western medicine, the claim number of Bell's palsy(G510) is the most. In oriental medicine the inpatients claim number of Deviated eye and mouth(J01) is the most, while outpatients claim number of the other facial palsy(J013) is the most. Conclusions : Medical database of HIRAS provided comprehensive and vast information on epidemiologic characteristics and treatment, which can be more reliable data to expect medical demand for facial palsy in condition that accurate diagnosis and standardized treatment is delivered in clinical settings.

• 보건행정학회지
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• 제14권4호
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• pp.88-113
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• 2004

Starting from April, 2003, new pre-review system has been introduced and implemented to reduce unnecessary conflict with medical care organizations caused by current retrospective claim review system and to enhance efficiency of review system. The main purpose of pre-review system is to educate doctors to contrive adequacy of medical services. This research mainly focuses on effectiveness of pre-review system's influence on physicians' behavior changes. The analysis-participants were drawn from 1,449 clinics which implemented pre-review system, since April of 2003. The research results are as followings. First, the amount per claim has reduced by $\\3,154$, days of visit per claim by 0.1 day, and amount per visit by $\\412$, which were statistically significant. Second, anesthesiologists have decreased in three indicators the most, and the internists had least of changes. Third, the amount per claim and days of visit per claims has dropped significantly on physicians with less periods of practice and physicians with more ages. Fourth, the clinics without the expensive medical equipments, the city clinics showed significant decrease on days of visit per claim. Fifth, in intervention methods, the one-to-one education showed more significant decrease on amount per visit rather than information feedback by paper. In conclusion, the pre-review system have an impact on self-imposed physician behavioral change. The outcome of this research may be utilized for future extension implementation of pre-review system. Furthermore, it is showed that ability of transitions in medical services review system according to the future transition of payment system and context of health service policy.

• 보험의학회지
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• 제27권1호
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• pp.6-8
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• 2008

Korean life insurance medical association's public periodical, the Journal of Korean Life Insurance Medical association (J Kor Lif Ins Med Assoc, JKLIMA) is now published $27^{th}$ issue. From this issue there are some changes of the journal than before. It is because general requirements for medical journals from the Korean association of medical journals editors. It can be remedy for the development of JKLIMA, in terms of academicism. First, the style of the manuscripts, medical opinion of insurance administration is added. This style of manuscript needs not keep the format of original research article such as background, materials, results, and discussion. Secondly, It is emphasized that submitted manuscripts must be reviewed by peer reviewers. Thirdly, we will make an effort to globalization of our journal. Lastly the publication period has been changed from annual to biannual. The publication date will be at March 31st and September 30th every year.

• Journal of Preventive Medicine and Public Health
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• 제22권2호
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• pp.259-267
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• 1989

The objective of this study was to analyze the influence of the hospital and insurer in causing delayed reimbursement of medical insurance benefits. We analyzed major variables at three different sized hospitals to examine the effect of the hospital and insurer using the two-way ANOVA method. The results were as follows: 1. The time interval between claim by hospitals and payment of the benefit was statistically different according to hospital in both admission and outpatient care. 2. The time needed by the insurer for investigating the claims was statistically different according to hospital and insurer in both admission and outpatient care. There was interaction between the hospital and insurer factors in outpatient care. 3. Although there was interaction between the hospital and insurer factors in admission care, the time interval between claim and payment was statistically different. In outpatient care, the payment interval between claim and payment was also statistically different according to the hospital and insurer.